Week 2
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Name: NRNP_6531_Week2_Assignment_Rubric
|
|
Novice |
Competent |
Proficient |
|
HPI statement |
0 (0%) – 5 (5%) Poorly written HPI statement. Incomplete ideas and sentences. Lacks basic history taking skills |
6 (6%) – 10 (10%) Well written HPI statement but may be missing 1-2 key components from the history |
11 (11%) – 15 (15%) Clearly written HPI statement with comprehensive information gathering from case questions. |
|
History |
0 (0%) – 6 (6%) Incomplete history missing 3 or more aspects of the OLDCARDS critical to patient’s diagnosis. |
7 (7%) – 8 (8%) Fairly complete history covering most of the requirements but may be missing 1-2 aspects of OLDCARDS critical to patient’s diagnosis. |
9 (9%) – 10 (10%) Complete history covering all critical components of a focus exam. Includes all aspects of OLDCARDS |
|
Physical Exam |
0 (0%) – 6 (6%) Incomplete physical examination. May be missing 3 or more key exam findings that are critical to patient’s diagnosis. |
7 (7%) – 8 (8%) Fairly complete physical examination but may be missing 1-2 key exam findings critical to patient’s diagnosis. |
9 (9%) – 10 (10%) Complete physical examination covering all critical components of a focus exam. |
|
Testing |
0 (0%) – 6 (6%) Includes 3 or more inappropriate exams or tests. May include contraindicated testing. |
7 (7%) – 8 (8%) Tests ordered are generally apprropriate. May include 1-2 unnecessary exams or tests. |
9 (9%) – 10 (10%) Tests that are ordered are appropriate for patient and cost effective. |
|
Differential Diagnosis Summary |
0 (0%) – 9 (9%) Primary diagnosis may be wrong.Differential diagnosis list too brief and inconclusive. May be missing 3 or more critical components. |
10 (10%) – 14 (14%) Correct primary diagnosis identified. Well written differential diagnoses. May be missing 1-2 critical components. Priority list may be out of order |
15 (15%) – 20 (20%) Primary diagnosis identified. Clearly written differential diagnoses. |
|
Plan for patient |
0 (0%) – 15 (15%) Poorly written plan. May be missing 3 or more key issues that are critical to patient’s diagnosis. |
16 (16%) – 25 (25%) Well written plan but may be missing 1-2 key issues critical to patient’s diagnosis. |
26 (26%) – 30 (30%) Clearly written plan covering all critical components for patient’s final diagnosis. |
|
Exercises |
0 (0%) – 2 (2%) Correctly answered 0-69% of the clinical questions. |
3 (3%) – 4 (4%) Correctly answered 70-89% of the clinical questions. |
0 (0%) – 5 (5%) Correctly answered 90-100% of the clinical questions. |
|
Total Points: 100 |
Name: NRNP_6531_Week2_Assignment_Rubri
Review this week’s Learning Resources. Consider how to assess, diagnose, and treat patients with integumentary conditions.
· Access i-Human from this week’s Learning Resources and review this week’s i-Human case study. Based on the provided patient information, think about the health history you would need to collect from the patient.
· Consider what physical exams and diagnostic tests would be most appropriate to gather more information about the patient’s condition.
· Reflect on how the results would be used to make a diagnosis.
· Identify three to five possible conditions that may be considered in a differential diagnosis for the patient.
· Consider the patient’s diagnosis. Think about clinical guidelines that might support this diagnosis.
· Develop a treatment plan for the patient that includes health promotion and patient education strategies for patients with integumentary conditions.
Kaylee Hales is 25 years old , comes to the clinic with a new rash, she is 5’5
Report generated on 3/13/2022, 11:45:29 PM America/Denver
Performance Overview for Kayla Grey on case Victoria Lewis V5.1 PC PL
The following table summarizes your performance on each section of the case, whether you completed
that section or not.
Time spent: 8hr 45min 7sec
Status: Submitted
Case Section Status
Your
Score
Time spent Performance Details
History Done 100% 3hr 11min
57sec
48 questions asked, 18 correct, 0 missed relative to the expert’s list
Physical exams Done 69% 1hr 34min
2sec
24 exams performed, 3 correct, 2 missed relative to the expert’s list
Key findings
organization
Done 43min
31sec
7 findings listed; 6 listed by expert
Problem
statement
Done 8min 32sec 70 words long; expert’s was 77 words
Body system
classification
Done 100% 13sec 1 of 1 correctly picked plus 0 extras
Differentials Done 40% 6min 42sec 5 items in the DDx, 2 correct, 3 missed relative to the expert’s list
Differentials
ranking
Done 100%
(lead/alt
score)
40%
(must
not miss
score)
6min 11sec
Tests Done 100% 7min 22sec 1 test ordered, 0 correct, 0 missed relative to the expert’s list
Diagnosis Done 100% 7sec
Management
plan
Done 1hr 26min
3sec
233 words long; expert’s was 99 words
Exercises Done 93%
(of
scored
items
only)
7min 10sec 4 of 5 correct (of scored items only) 1 partially correct
Attempt: 2282253
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https://www.coursehero.com/file/137891175/WK2AssgnGreyKpdf/
Report generated on 3/13/2022, 11:45:29 PM America/Denver
History Notecard by Kayla Grey on case Victoria Lewis V5.1 PC PL
Use this worksheet to organize your thoughts before developing a differential diagnosis list.
1. Indicate key symptoms (Sx) you have identified from the history. Start with the patient’s reason(s) for the encounter
and add additional symptoms obtained from further questioning.
2. Characterize the attributes of each symptom using “OLDCARTS”. Capture the details in the appropriate column and
row.
3. Review your findings and consider possible diagnoses that may correlate with these symptoms. (Remember to consider
the patient’s age and risk factors.) Use your ideas to help guide your physical examination in the next section of the
case.
HPI Sx =rash
Sx
=
Sx
=
Sx
=
Sx
=
Sx
=
Onset 36 hours
Location inner thighs and left inner
forearm
Duration constant
Characteristics itching and tender
Aggravating none
Relieving none
Timing /
Treatments
none
Severity unknown
Attempt: 2282253
This study source was downloaded by 100000848518627 from CourseHero.com on 06-08-2022 18:33:06 GMT -05:00
https://www.coursehero.com/file/137891175/WK2AssgnGreyKpdf/
Report generated on 3/13/2022, 11:45:29 PM America/Denver
Problem Statement by Kayla Grey on case Victoria Lewis V5.1 PC PL
V.L. is a 25 y/o Caucasian female that presents with a rash to bilateral inner thighs and inner left forearm x 36 hours that is
itchy and becoming tender. This rash is erythematous with vesicles at various stages on inner thighs and erythematous with
vesicles in a linear pattern on inner left forearm. This rash is most likely caused from contact with an allergen after a weekend
trip to Napa.
Attempt: 2282253
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https://www.coursehero.com/file/137891175/WK2AssgnGreyKpdf/
Report generated on 3/13/2022, 11:45:29 PM America/Denver
Management Plan by Kayla Grey on case Victoria Lewis V5.1 PC PL
Dx: Allergic Contact Dermatitis
Therapeutic treatments:
non-pharmacological- gentle cleansing of affected area with lukewarm water and nonfragranced antibacterial soap or astringent
soak, cool wet compresses, and avoid scratching.
Pharmacological- topical and/or systemic steroids and antihistamines.
Triamcinalone 0.5% topical cream applied to affected area BID x 5-7 days
Medrol dose Pak 4mg as directed (24mg on day one, 20mg on day 2, 16mg on day 3, 12mg on day 4, 8mg on day 5, and 4mg
on day 6)
Benadryl 12.5-25mg OTC every 4-6 hours as needed for itching
No consults needed at this time.
Education:
This patient has risk factors of hiking which can expose patient to numerous plants and insects, use of hot tub, use of new
suntan lotion and ingestion of new food/drink. Education should be provided on avoiding allergen if at all possible and if skin
comes into contact with it, such as poison ivy, poison oak, and poison sumac, the skin should be washed with mild soap and
water immediately. There is also a patch test method when using new lotions, soaps, perfumes, etc. that may prevent future
allergic reactions. Most importantly avoid scratching to prohibit further skin irritation and spread of reaction.
With this treatment the patient should see some relief in 1-2 days, but if it worsens the patient should come back into clinic for
futher evaluation and treatment due to the possibility of a secondary infection.
Attempt: 2282253
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https://www.coursehero.com/file/137891175/WK2AssgnGreyKpdf/
Electronic Medical Record by Kayla Grey on case Victoria Lewis V5.1 PC PL
History of Present Illness
Category Data entered by Kayla Grey
Reason for Encounter rash to upper thighs and left forearm
History of present illness V.L. is a 25 y/o Caucasian female that presents today with a rash that is itchy and
getting tender to bilateral upper thighs and inner left forearm. The rash started
approximately 36 hours ago after hiking in the woods and “bush whacking” her way
back to the trail. No treatments have been tried and no known aggravating or
alleviating factors.
Past Medical History
Category Data entered by Kayla Grey
Other active problems none
Medical, surgical, obstetric,
hospitalizations
none
Medications
Category Data entered by Kayla Grey
Rx (medications) Birth Control Pill
Allergies
Category Data entered by Kayla Grey
Allergies Ceclor or Cefaclor – hives as a child
Preventive Health
Category Data entered by Kayla Grey
Preventive health Up to date on all immunizations
Exercises regularly
Normal American diet
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Family History
Category Data entered by Kayla Grey
FHx (family history) Maternal grandfather died of CVD at age 81, grandmother alive age 88 prior heart
attack, stent, and HTN
Mother alive and well
Father alive, HTN
Brothers ages 35 and 32 alive and well
sister age 21 alive and well
Social History
Category Data entered by Kayla Grey
SHx (social history) Has a Boyfriend
monogamous relationship
sexually active- BCP
Reports occasional alcoholic drink
Denies tobacco or drug use
Review of Systems
Category Data entered by Kayla Grey
General/Constitutional Generally well appearance. No fever or fatigue. No excessive weight gain or weight loss.
Skin/Breast Reports rash to bilateral upper thighs and inner left forearm. No other skin or breast
changes.
HEENT & neck No problems with headaches, double or blurred vision, no eye redness, difficulty with
night vision, problems hearing, ear pain, sinus problems, chronic sore throat, or
difficulty swallowing. No problems with nasal drainage or congestion.
Cardiovascular No complaints.
Respiratory No cough, shortness of breath, or breathing difficulties
Abdomen/Gastrointestinal No complaints.
Genitourinary No complaints.
Musculoskeletal No problems with muscle or joint redness, swelling, muscle cramps, joint stiffness, joint
swelling or redness, back pain, neck or shoulder pain or hip pain.
Allergic/Immunologic No complaints.
Lymphatic/Endocrine No complaints.
Hematologic No complaints.
Neurological No problems with dizziness, fainting, spinning room, seizures, weakenss, numness,
tingling, or tremors.
Psychological No complaints.
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Report generated on 3/13/2022, 11:45:29 PM America/Denver
Physical Exams
Category Data entered by Kayla Grey
General A/O x 4, dressed appropriately. BP 116/80, pulse 60BPM, respirations 13, Spo2 94%,
and temperature 98.6
Skin/Breast Left forearm have itchy erythematous papules linear with vesicles. Bilateral inner upper
thighs have raised erythematous papules with vesicles in various stages.
HEENT & neck Trachea midline, thyroid firm and normal size for age and gender, no nodules.
Cardiovascular PMI 5th ICS at the MCL. S1 and S2 noted. No murmurs, gallops, or rubs.
Respiratory Normal respirations, no shortness of breath or distress. No wheezing, crackles, or rales
upon auscultation. No distention, scars, or masses noted.
Abdomen/Gastrointestinal Flat, symmetric, no scars, deformities, striae, or lesions. Hyperactive bowel sounds in
all quadrants. No pain, tenderness, massess, or pulsations. No guarding or rebound
tenderness, no hepatosplenomegaly, liver span normal, spleen not palpable.
Genitourinary N/A
Musculoskeletal No stiffness in joints. No swelling, deformities, cyanosis, clubbing or edema in
extremeties.
Osteopathic N/A
Neurological N/A
Psychological N/A
Lymphatic/Endocrine No swollen lymphnodes.
Attempt: 2282253
This study source was downloaded by 100000848518627 from CourseHero.com on 06-08-2022 18:33:06 GMT -05:00
https://www.coursehero.com/file/137891175/WK2AssgnGreyKpdf/
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